The DOC clinic has patients with a high prevalence of multiple chronic illnesses, mental health conditions, and socioeconomic challenges including the uninsured/underinsured. These complexities lead to above-average utilization of emergency and hospital services by DOC patients for issues that could be much better addressed in an outpatient setting. This project will build on the success of the HomeBASE program by creating a prototype of the other evidence-based high-utilizer interventions capable of matching the burden of disease and managing the frequent exacerbations experienced by the DOC’s high-need patients.

This proposal explores new models of primary care, combining proactive outreach and extension of privileges such as same-day walk-in access, with immediately available acute care at a level similar to urgent care/moderate intensity emergency care, but in a lower-cost setting. It does so by creating a “clinic-within-the-clinic” acute illness/chronic care platform specializing in common exacerbations of chronic illness, to minimize disruption to clinic flow and reduce the need to reflexively call 911 to transport patients to an ED. In addition, this will be an experience in team-based care for trainees, with resident providers able to practice real-time collaboration and delegation with an APP colleague.